BBI Contributing Editor

LAS VEGAS, Nevada – The Microsoft Healthcare Users Group-sponsored Windows on Healthcare conference held here last fall might be described as "HIMSS lite." MS-HUG had fewer attendees and vendors than one finds at the sprawling Healthcare Information and Management Systems Society (HIMSS; Chicago, Illinois) gatherings, but the quality of the presentations was as good as, and in some cases better than, those at HIMSS.

Some themes of the Windows on Healthcare conference included users moving to wireless, secure, mobile access to health care applications, with the web browser (or plug-in) becoming the de facto, universal interface. The convergence of the web phone/browser also was seen, with new devices coming from Samsung (Ridgefield Park, New Jersey), Microsoft (Redmond, Washington), Symbol Technologies (Holtsville, New York) and others. The resurgence of smart cards was a theme for enabling both providers and patients with access to patient records. Microsoft made clear its support for Bluetooth wireless networking at the operating system level.

If MS-HUG is representative, 2000 was the year of mobile, wireless, secure, web-enabled, Internet-based medical applications. Of course, compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements is lurking in the background, but as providers and vendors alike await clarification and finalization of HIPAA requirements, they are moving ahead rapidly to adopt commercial technology and apply them to health care applications. MS-HUG was noteworthy for keynote speakers who are intimately involved with health care and doing some rather innovative work that can improve the quality and change the direction of health care in the U.S.

One keynoter, Dr. Brendt James, executive director of the Institute for Health Care Delivery Research (Salt Lake City, Utah), dealt with the role of computer-based patient record (CPR) systems in reducing adverse drug events (ADEs), a major conference theme. James noted that the rate of ADEs, widely reported by the Institute of Medicine (IOM; Washington) at 98,000 deaths per year, was dramatically lower than actual occurrences. Even at those rates, the cost to the U.S. health care system was $15 billion a year. The IOM had reported that adverse events occurred among 3% to 4% of hospitalized patients, and that 10% of these resulted in patient deaths. It is generally reported that 2% of hospitalized patients have adverse drug events, each of which costs up to $4,700 in additional hospital costs and charges. However, James said that the actual rate of ADEs depends on how you detect them. If you depend upon provider voluntary reporting, the rate appears to be very low – about .025%. If you do retrospective chart reviews the rate increases by a factor of 10, to 0.25% of patients. However, if you use a computerized patient charting system, programmed to detect the antidotes administered for overdoses, the rate increases another 10 times to 2%. The CPR system finds 100 times as many events as the staff report voluntarily. That was the bad news. The good news, James said, is that these events can be reduced 66% to 75%, but the bad news was that even after such reductions, the deaths or serious complications of ADEs will still be substantially higher than the Institute of Medicine has reported.

In looking at the etiology of ADEs, James pointed out five areas: drug administration errors, ordering errors, patient factors, physiologic factors and pharmacological factors. The most significant cause of ADEs, he said, is ignoring known drug reactions, followed by failure to adjust for reduced renal function of patients; those two causes alone account for over half of all ADEs. Other important causes included failure to adjust dose to patient age, failure to adjust dose to patient's body mass, an error in the dosage on the order and failure to take into account known hematologic factors.

The largest cause of problems, known allergies to drugs, can be avoided by reconsidering the prescription of these drugs with known problems. The others could be easily tracked by either a point-of-care CPR or hospital pharmacy Rx computer system. Vendors of point-of-care CPR systems for the ICU, ambulatory care and general ward should take this into the design of their systems and create warnings and systems which make it difficult for providers to overlook these easily avoidable sources of ADEs. This alone could justify the cost of the entire CPR alone, as severe ADEs result in an extra 108,000 patient days, at a cost of perhaps $1,500 to $2,800 per day. Certainly, vendors seeking to justify the costs of their CPR systems should not overlook the potential savings of being able to reduce ADEs by over 75% by the use of a well-designed CPR at the point of care. Of course, your CPR has to be well-designed and able to actually track and alert the staff to such potential problems. One such system that can do this is the 3M Help system used at Latter-Day Saints Hospital (LDS; Salt Lake City, Utah) and throughout some of the other Intermountain Health Care system hospitals. The Help system at LDS provides surveillance of more than 202,000 inpatients yearly for the occurrence of medication errors. James advises those who wish to reduce their medical errors to standardize processes by making "smart cogs" that can adapt to individual patient needs. By doing so, he said he believes that patient injuries could be cut in half within five years.

Another keynoter, William George, CEO of Medtronic (Minneapolis, Minnesota), described that company's vision for health care 2010, one which will expand its focus to providing products and services to those with disabilities, not just during acute episodes when they are hospitalized, but across the continuum of care. Medtronic is addressing these needs by expanding the capabilities of the implanted medical devices it produces so that they can provide communications to the patient's health care providers on a virtually real-time basis. Examples include implanted cardiac defibrillators that transmit patient data detected by the implanted device to the patient's caregivers so that early harbingers of developing problems can be detected and treated to avoid unnecessary and expensive inpatient episodes.

Bob McDowell, vice president of Microsoft (Redmond, Washington), noted that in terms of the adoption of wireless connectivity technology, the U.S. lags behind many other countries with an adoption rate of less than 30%. McDowell foresees the Internet as becoming a ubiquitous infrastructure, available to all, around the clock. He also sees it as the key to the integration of devices, including medical devices. Convergence of commercial devices that will facilitate new medical applications also are occurring, McDowell said. An example is the convergence of today's cell phone and personal data assistant devices into a single, new device.

New products debut

A new package of an existing Nonin Medical (Plymouth, Minnesota) pulse oximeter showed up from QRS Systems (also Plymouth). The company is offering a series of medical device PC cards that plug into Windows CE devices such as the Compaq palm device or the Hewlett Packard Jourada series. So far, there is a SpiroCard, an ECG analysis card and a pulse oximeter. A combination of these two and a new NIBP card are in the works as well. The list prices of these cards range from $1,000 to $2,000. These will transform the popular physician hand-held into a medical screening device. These devices are smaller than anything either Masimo (Irvine, California) or Nellcor (Pleasanton, California) are currently offering. However, they may not have the noise immunity or low perfusion sensitivity of those firms' devices.

Windows CE devices got a robust relational database in Visual CE, useful for creating CE device screen forms compatible with Syware's (Cambridge, Massachusetts) ODBC-compliant driver for Windows CE. In version 5.0, developers get a robust but cost-effective ($79) database. Several vendors were showing applications using databases, such as PocketChart by Data Critical (Bothell, Washington) which comes with 300 templates that support workflow in a variety of clinical settings. PocketChart is implemented on Windows CE hand-held PCs that support 32M (or more) of memory.

Other interesting products include a miniature VGA resolution projector that can be built into a pair of eyeglasses, or clipped on, to project computer images into the wearer's field of view. Brightness is increasing from 50 foot-lamberts to about 3000 foot-lamberts, with preliminary applications in medical device repair and surgery. MicroOptical (Westwood, Massachusetts) is developing this technology.

ILabs, a joint effort of Networld and Interop, has proposed IP (version 6) to replace the current 32-bit addresses with a new scheme that would use 128-bit addresses. This would assure expansion for any conceivable address requirements on the Internet that are now contemplated. Prototypes of this technology are already available.

Enabling all these wireless applications were new PC card 802.11 and 802.11b wireless cards. Proxim (Mountain View, California) was showing its RangeLAN, a new 802.11 compatible device operating at up to 11 megabytes/second. Symbol Technologies also was showing 800.11b compatible wireless LANs that frequency-hop and achieve 2 megabytes/second/access point.

To help developers of hand-held PCs and palm-tops, Link Medical Computing (Needham, Massachusetts) was offering its LinkTools interface Kits, a set of development tools that make implementing inbound and outbound HL7 interfaces simple. The toolset includes: an HL7 mapper, receiver, transmitter, database engine, scheduler and manager -among others. It is an ideal alternative to the Andover Working Group's solution for HL7 interfacing. Typical costs for vendors to integrate this toolset range from $695 to $6,000. This toolset is used by Siemens, Collins and several other medical suppliers.

For those who find using a computer application too much of a leap into the future, there was the AlphaSmart 3000 laptop word processor, a product of Smart Input (Sparks, Nevada). This device is a keyboard with a 4-line, 40-character/line display that allows doctors to type in information and interface it to a real computer. Given that most doctors don't type (at least not during patient encounters), this product is not likely to have a great rush to adoption, even though it integrates well with both PC and MacIntosh computer platforms.

Eclipsys (Delray Beach, Florida) was showing enhanced versions of its Sunrise Acute-Care Clinical Manager. However, this contains none of the Emtek point-of-care, computer-based record manager components Eclipsys acquired several years ago.

Those interested in middleware products for implementing HIPAA should check out Ensure Technologies' (Ann Arbor, Michigan) family of products. This company offers a range of products including hacker-proof systems, servers and communications. Ensure Technologies showed another interesting security component – a USP-connected RF (900 MHz) proximity system that senses the badge of a health care provider and manages screen blanking and passwords to secure displays that may contain sensitive patient data from the eyes of unauthorized bystanders or other providers. When one authorized user moves away from the computer, the system blanks the screen (or initiates a screen saver) within three seconds. When that user returns, it unblanks the screen within another three seconds of sensing the user, restoring the screen to the exact point where it was initially blanked. If a different, but authorized user comes within unblanking distance of the system, this software will close the first user's applications, unblank the screen and provide a universal logon screen for the second user to sign in. Sign-in requires a password in addition to the proximity of the badge. If coupled with a biometic sensor, such as a fingerprint scanner, this provides very robust and foolproof ID of the person that is interacting with the terminal.

Almost none of the CPR application providers are showing hardware. Rather, they are all encouraging end users to select their own. This is probably the biggest remaining source of problems with the widespread implementation of such products. While this should create an opportunity for Tremont Medical (Aston, Pennsylvania), Planar Systems (Beaverton, Oregon) and others, these companies have not been able to capitalize on hardware configurations that compete with procurement from local computer suppliers.

Lexmark International (Lexington, Kentucky) was showing its new, Optra C710 Color Laserjet printers, which start at less than $2,000. These provide 1200 x 1200 bit color at 3 to 16 pages per minute, with reasonable per-copy costs. This is just one of many new products the company is offering in the sub-$5,000 range, and they are ideally suited for hospital departments or small-to-medium-sized physician offices. Lexmark is not available directly but sells through a groups of dealers and distributors around the country.

One of the impressive things from the HS-HUG conference was the rapid response by Microsoft to provide core-technologies upon which secure and robust medical applications could be built. The announcement of Windows CE Version 3.0, with its enhanced security, user interface, browsing and wireless support, were excellent examples. Microsoft, a Bluetooth consortium partner, is building the TCP/IP stacks and RF foundation for Bluetooth, provide wireless networking into Windows CE, giving it a rich, high-level set of functions that will ease the development and expedite development time to create and debug medical applications.

Product enhancements

JMJ Technologies (Marietta, Georgia) was showing a vastly expanded family of physicians' office CPR products. This relatively young company has expanded from products aimed at two physician office specialties to four at last year's HIMSS meeting, to eight at the MS-HUG conference. These variations on their common workflow theme recognize the differences in the way a pediatric practice differs from a surgical practice or an oncology practice. JMJ is emerging as one of the premiere small providers of functional and cost-effective CPR systems for medical offices. The company is little-known due to inadequate marketing and sales channels, but is now turning its attention to expanding awareness of its products by highlighting the success stories its customers have achieved in various clinical settings. The company also is working on completing the web enabling of its products, a task which will occupy it for approximately another year.

If there was one application that multiple vendors seem to have discovered, it was physician prescription services using wireless, hand-held devices. At least six companies on the exhibit floor were showing such programs, which allow the prescribing doctor to access the formulary of the patient, based on their health plan, and then retrieve a list of drugs, which have the "approved" drugs for the patient "flagged" on the display, along with the relative costs of the drugs. This is intended not only to expedite the management of patient prescriptions, but also to provide new decision support tools at the point of care related to allergies, interactions and costs – helping the physician to prescribe both effective and cost-effective drugs for particular patients and conditions.

Several hand-held devices and phones were showing implementations of Sybase's (Emeryville California) new micro-relational database, a scaled-down version of its well-known full-features relational databases, intended for limited memory, limited processor devices that required embedded database capabilities.

There were several presentations on achieving compliance with HIPAA, and the weight of opinion seemed to be that within a year, the key components that are presently unspecified or unclear will be specified, clear and awaiting implementation by vendors and providers alike. In spite of the public opposition and concerns about "universal health care identifiers," it seems that the Department of Health and Human Services has only delayed its implementation, not rethought it.